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FSRH intrauterine contraception guideline

Intrauterine contraception

Eligibility

Health professionals should be familiar with the UK Medical Eligibility Criteria for intrauterine methods

Efficacy

Women should be advised of the very low failure rates associated with use of intrauterine contraception (IUC)

The most effective methods of IUC are the levonorgestrel intrauterine system (LNG-IUS) methods and T-shaped copper intrauterine devices (Cu-IUDs) with at least 380 mm2 copper and copper bands on the transverse arms

Insertion of IUC and duration of use

A medical and sexual history should be carried out as part of the routine assessment for IUC to assess suitability for use of the method and need for STI testing

In asymptomatic women attending for insertion of IUC there is no need to wait for STI screening results or to provide antibiotic prophylaxis providing the woman can be contacted and treated promptly in the event of a positive result

Prophylactic antibiotics are not routinely required for the insertion or removal of IUC even in women with conditions where the risk of infective endocarditis may be increased

The 52 mg LNG-IUS (Mirena®)* can be used to provide endometrial protection in conjunction with estrogen therapy for up to 5years (outside product licence)

Health benefits and risks

Use of a Cu-IUD may be associated with a reduced risk of endometrial cancer and cervical cancer

The 52 mg LNG-IUS* is effective in reducing menstrual blood loss and can be used in the management of heavy menstrual bleeding

Women considering the LNG-IUS can be informed that systemic absorption of progestogen occurs with these devices. The 13.5 (Jaydess®)* and 52 mg LNG-IUS* have similar side-effect profiles (such as acne, breast tenderness/pain and headache) and hormonal side-effects often settle with time. Rates of discontinuation due to side-effects are not significantly different from Cu-IUD users

Women should be advised that existing evidence fails to support a negative effect on libido associated with IUC use

Weight gain has been observed with use of IUC. There is no significant difference between hormonal and non-hormonal intrauterine methods and evidence to support a causal association is lacking

In the 3–6 months following IUC insertion women may experience irregular, prolonged or frequent bleeding but menstrual bleeding patterns tend to improve with time

At 1 year infrequent bleeding is usual with the LNG-IUS and some women will experience amenorrhoea

Discontinuation due to bleeding and pain are similar for different types of framed and unframed Cu-IUDs

Evidence does not support a link between breast cancer and use of the LNG-IUS

Non-hormonal contraception is most appropriate for women with a history of breast cancer. Any consideration of the LNG-IUS should be carried out in consultation with the woman's cancer specialist

Evidence suggests there is little or no increased risk of venous thromboembolism or myocardial infarction associated with the use of a LNG-IUS

Ectopic pregnancy

The overall risk of ectopic pregnancy is reduced with use of IUC when compared to using no contraception

If pregnancy does occur with an intrauterine method in situ, the risk of an ectopic pregnancy occurring is increased and in some studies half of the pregnancies that occurred were ectopic

Data are insufficient to determine if the 13.5 mg LNG-IUS* is associated with a greater risk of ectopic pregnancy than other IUC methods

IUC users should be informed about symptoms of ectopic pregnancy. The possibility of ectopic pregnancy should be considered in women with an intrauterine method who present with abdominal pain especially in connection with missed periods or if an amenorrhoeic woman starts bleeding. If a pregnancy test is positive an ultrasound scan is urgently required to locate the pregnancy

Complications of IUC

The risk of expulsion with IUC is around 1 in 20 and is most common in the first year of use, particularly within 3 months of insertion

There is no need to delay insertion of an IUC post-abortion providing a woman has been informed of the small increased risk of expulsion

Although ovarian cysts may occur when using the LNG-IUS, most cysts are asymptomatic and resolve spontaneously

The rate of uterine perforation associated with IUC is up to 2 per 1000 insertions and is approximately six-fold higher in breastfeeding women

Return of fertility after IUC use is generally similar to fertility rates after discontinuation of oral contraceptives and barrier methods

Cu-IUD users with recurrent bacterial vaginosis or vulvovaginal candida may wish to consider an alternative method of contraception

At the time of insertion

Valid consent should be given by women prior to both pelvic examination and IUC insertion or removal

An appropriately trained assistant who can monitor the condition of the woman and assist in an emergency should be present during insertion of IUC

There is no evidence from current trials to support the use of topical lidocaine, misoprostol or non-steroidal inflammatory drugs (NSAIDs) for improving ease of insertion or reducing pain during insertion of intrauterine methods

Local anaesthetic block administered by cervical injection is not routinely required for IUC insertion but should be offered when cervical dilatation is required or difficult IUC insertion or removal is anticipated/experienced

NSAIDs can be offered to women who experience pain after insertion of an intrauterine method

A bimanual pelvic examination should be performed on all women before inserting IUC

There is no evidence to suggest that cervical cleansing prior to IUC insertion reduces subsequent pelvic infection

Management of complications

There is no evidence as to the most appropriate treatment option for women with unscheduled bleeding with the LNG-IUS. For women with unscheduled bleeding who wish to continue with the LNG-IUS and are medically eligible, a combined oral contraceptive could be tried for up to 3 months (this can be in the usual cyclic manner or continuously without a pill-free interval—unlicensed use)

NSAIDS can be considered in the management of problematic bleeding with use of Cu-IUDs

Insertion or reinsertion of an intrauterine method can be carried out in asymptomatic women with actinomyces-like organisms (ALOs)

There is no need to remove IUC in asymptomatic women with ALOs

IUC removal is not routinely required in women with pelvic inflammatory disease but it should be removed if there is no response to treatment (approximately 72 hours)

Women should be offered instruction on how to check for the IUC and advised that if the threads cannot be felt the device may have perforated the uterus or been expelled. Additional contraception should be used until they seek medical advice

Women should be advised to seek medical assistance at any time if they develop symptoms of pelvic infection, pain, abnormal bleeding, late menstrual period (IUD), non-palpable threads or can feel the stem of the IUC

Other issues to consider

Women requesting intrauterine methods should be informed about the use of additional precautions for protection against STIs and advised about the appropriate timings of STI testing after an episode of unprotected sexual intercourse

Health professionals should inform women about the availability of EC and when it may be required with intrauterine methods

A routine follow-up visit can be advised after the first menses following insertion of IUC or 3–6 weeks later. However, it is not essential and it may be more important to advise women as to signs and symptoms of infection, perforation and expulsion, returning if they have any problems relating to their intrauterine method

Mooncups and tampons do not appear to be associated with an increased risk of IUC expulsion

Use of intrauterine methods should not be restricted based on parity or age alone

For women with cardiac disease the decision to use IUC should involve a cardiologist. The IUC should be fitted in a hospital setting if a vasovagal reaction presents a particularly high risk, for example, women with single ventricle circulation, Eisenmenger physiology, tachycardia or pre-existing bradycardia

*Mirena (52 mg) and Jaydess (13.5 mg) were the only LNG-IUS that were listed and reviewed in the full guideline.

Shelley Raine explains why the UKMEC is so important in general practice and how to apply the recommendations when seeing women, both for the initiation of a contraceptive method and continuation of a treatment.